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Leveraging Data Analytics to Complement Value-Based
Approach
Session 97, February 13, 2019
Nathan Riggle, Director of Analytics, Mercy ACO
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▪ An employee of Mercy ACO
▪ Mercy ACO is a client of Innovaccer
▪ Innovaccer has sole ownership and rights to their data activation platform
Conflict of Interest
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• Mercy ACO background
• Strategic priorities
• Current data systems in the industry today
• Mercy ACO’s Strategy
– Data Activation
– Analytics
– Patient engagement
• Mercy ACO’s Performance
• Closing thoughts
• Q&A
Agenda
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• Develop a complete patient picture by leveraging multiple data sources
• Recognize the need for data-driven approaches to improve workflows,
close gaps in care, increase communication, reduce SNF and ED
utilization, and promote community engagement
• Explain the key elements for creating the necessary infrastructure to
redefine the process of healthcare delivery
• Develop growth strategies with the use of data analytics to complement
a value-based approach
Learning Objectives
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Mercy ACO Background
• Mercy ACO as our foundation
– Mercy ACO is a subsidiary of MHN
– 6 (regional) ACO Chapters
– 67 of 99 Iowa Counties
• 2012 Track 1 MSSP “Mercy ACO”
• 2017 moved to ‘downside risk’
– (1) Track 3 MSSP (up/downside risk)
– (1) Track 1+ MSSP (up/downside risk)
– (2) Track 1 MSSPs (Rural/Urban)
– (5) Commercial Shared Savings Programs
– Partnered On/Off Exchange Product
• Independent & Specialty Groups
– 195+ Participant Organizations
– 3,500+ Providers
• Government & Commercial Contracts
– 310,000+ Covered Lives
– 20+ Value Based Contracts
– 3-day SNF Waiver
North
Iowa
Central
Iowa
Siouxland
Dubuque
Clinton
Waterloo
Medicare Shared Savings Program
Commercial Shared Savings
Direct to Employer
Medicaid
Medicare Advantage
Partnered On/Off Exchange Product
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Mercy ACO’s data journey
1995 – Excel spreadsheet to track Diabetes and HTN
• Tracking a population greatly improved clinical outcomes
1998 - home grown SQL registry
• Lab data dump for HgA1c and LDL
2003 – 2012 – Free registries from QIO
• Manual Data Entry for HgA1c, LDL, BP, UACR
• Health Coaches introduced in 2004
2012 - MedVentive / McKesson
• Automated data entry –claims and EMR
2015 - Innovaccer
• Automated data entry –claims, EMR, PPMS, ADT
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Mercy ACO Strategic Priorities
▪ Manage risk for population
▪ Manage the total cost of care
▪ Lower network leakage
▪ Data-driven care management
▪ Identify growth opportunities
▪ Create value for population
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Often “care” looks like this…
Bad Delivery Systems
Duplication
of Effort
Gaps in
Communication/Care
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Where data systems look like this...
Disparate data systems Analysis-paralysisLack of interoperability
EH
R 1
EH
R 2
EH
R 3
EH
R 4
EH
R 5
EH
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EH
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EH
R 8
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Mercy ACO’s data needs
• Data activation - aggregation and normalization
• Metrics & Performance measurement
• MSSP metric reports
• Customized metrics
• Provider performance reports
• GPRO reporting
• Care management – workflow & documentation
• Work queues & Care Models
• Gaps in care
• Productivity monitoring
• Community Resources
• Security, Privacy, Data segmentation, and ACO Interoperability
• Analytics
• Episodes
• Network leakage
• Risk scoring – Clinical Documentation Improvement (CDI)
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Mercy ACO’s data infrastructure
Our data infrastructure is built from over 100 Clinical
System data feeds across Iowa, including 15+
different EMR brands.
This level of data integration provides a more
complete Patient Profile, for Care Management and
improved Patient Engagement.
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Innovations in care delivery are not
possible without activating the data
Population Health
Risk Management
Care Coordination
Quality & Performance
Reporting
Predictive Analytics
Electronic Health Records
Payer Claims
Billing Systems
Other
Clinical Systems (labs)
Public Sources (IHIN)
Disease Registry
Internal Sources
External Sources
Care
Management
Documentation
Platform
Risk Analytics
[ Data Activation Platform]
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Analytics for High-risk Segmentation
● Anyone with a hospital admission
○ For MSSP 17.6% are readmitted in 30 days (nationwide)
■ Mercy ACO readmission rate is 14.3%
● 3 or more ED visit in the previous 6 months
● Anyone with Dx of HF or COPD
● Anyone with 2 or more chronic diseases
● High cost or high risk score (top 1%)
○ Not a good population to improve health outcomes
■ 40% are dead when Identified by claims
● Other High Cost / High Risk strategies
○ Rising risk
○ Persistent high needs
○ High risk list reviewed by PCP for best opportunities
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Analytics to keep track of critical metrics
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Mercy ACO’s strategies and protocols for
high-risk patients
● Initiate with face-to-face visit
● Medical conditions and Medications
○ reviewed with teach back
● Red flags – warning symptoms and what to do
● Self Management Support and Goal setting
○ Motivational interviewing in the 5As Framework
■ Agree, Assess, Advise, Assist, Arrange
● Tobacco Screening and Cessation
● Depression Screening
● Advance Directives / Palliative Care
● Follow weekly for 6 weeks
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High-risk protocols: Populate automatically
when the bundle is created
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Engaging patients for value-based
outcomes
Event Based
• Admission – Discharge - Transfers
• Emergency Department Utilization
Improved Communication
• Continuum-of-Care virtual “Hand-
offs”
• “Social Media” (like) Patient Care
Timeline
Closing Gaps in Care
• Quality Metrics “Gaps-In-Care”
• Increasing Annual Wellness Visits
Community Engagement
• Community Resources
• Community Care Collations (C.C.C.)
• Community Health Workers
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Event Driven-Patient Engagement
• Admission-Discharge-Transfer (ADTs)
– 35+ Hospital ADT Connections + State Health Information Exchange
– “Strategy” triggers populate Health Coach daily schedules (work queues)
– Standardized process flows from Admission – Discharge – back to “Medical Home”
– Result: 7.14% ▼ in 30d Readmit Rate (14.3%) - 2017
“Strategies” Prioritization
&
Care Manager Alignment
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Event Driven-Patient Engagement
• Emergency Department Utilization
– Monthly Claims + “Real-Time” Electronic Health Record connection analytics
– “Strategy” triggers populate Health Coach daily schedules (work queues)
– Standardized process flow for “High Risk” patients – back to “Medical Home”
– Result: ▼ 6.65% ED Utilization/1k (632/k) - 2017
– Rural Health Coach Stories
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Gaps in Care- Patient Engagement
• Quality Metrics Closing “Gaps-In-Care”
– Single Patient profile based on numerous data sources
– Proactive/Reactive identification to close gaps-in-care
– Outreach/engagement via Health Coach Assistant/Clinic Staff
• Multiple Chronic Conditions
– Result: ▲ 14.26% Primary Care Services/1k (8,684/k) - 2017
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Gaps in Care- Patient Engagement
• Annual Wellness Exams
– Provider engagement and incentive alignment
– Monthly Claims monitoring – Chapter level to Provider level performance
reports
– Outreach/engagement via Health Coach Assistant/Clinic Staff
• Qualified members based on claims data
– Result: ▲ 9.15% Annual Wellness Rate (31%) - 2017
• *With some sites 70%+ Completion Rates*
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Communication- Patient Engagement
• Continuum of Care “Virtual Handoffs”
– Standardized workflows across the “continuum-of-care”
• Health Coach + Navigator + Acute Care Manager + Post Acute Health Coach
– Provides a mechanism that is patient centered
• Ensuring “warm handoffs”, “gaps-in-care” are closed and, aligns as well as
adjusts to our internal workflows versus the other way around.
• Result: ▲ 95.7 new engagements/Month/Health Coach - 2017
• “Social Media” (like) Patient Care Timeline
– Increased visibility of Care team interactions
– Patient Centered Approach
• Other linked Care Team members
• Personal information outside of demographics alone
• Patient Goals
• Linked (Community) Resources
• Result: ▲ 95.7 new engagements/Month/Health Coach - 2017
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Community - Patient Engagement
• Community Resources
– Sticky notes, rolodexes, Outlook contacts and, scraps of paper to an
electronic directory
– Non-clinical, but relevant resources to addressing social factors
(transportation, meals, etc).
– Result: “Virtual rolodex” of hundreds of geo-tagged community
resources and an ability to track linked community resources at the
patient level
• Expanding our platform & ACO processes to Community Partners
– Rural Network Participants (Nearly Complete)
– Community Health Workers (In Process)
– Partnered SNF Facilities (In Process) and
others (ongoing)
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Mercy ACO VBC Performance
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Key outcomes
● 7.14% reduction in 30d Readmit Rate (14.3%) - 2017
● 6.65% reduction in ED Utilization/1k (632/k) - 2017
● 14.26% increase in Primary Care Services/1k (8,684/k) - 2017
● 9.15% increase in Annual Wellness Rate (31%) - 2017
● ~280% increase in cumulative total return - 2017
● $100 million+ reduction in health care expense for Iowan’s (2012-17)
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Closing thoughts
• Abundance of data and information = Analysis paralysis
• Focus on the few measures and processes that will have the biggest impact
(Strategies)
– For Mercy ACO; Annual Wellness Exams, ED Utilization, and ADTs
• Connect with community partners/resources (they often eager to be
engaged)
• Select a vendor, or develop your platform, that is flexible enough to mimic
your processes/workflows, again not the other way around
• Looking ahead...
We’re excited for even more data to determine which of our
interventions have the biggest impact on Patient Engagement and improving
the health of our population.
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Questions?
• Contact information
– Nathan Riggle: <NRiggle@mercydesmoines.org>
• Organization information
– Mercy Accountable Care Organization
1449 128th St., Suite 110, Box 7
Clive, IA 50325
